Anorectal Disease Mohammad Reza Nikshoar MD Colorectal Surgeon

Anorectal Disease Mohammad Reza Nikshoar MD Colorectal Surgeon (Associate Professor ) Shahid Beheshti Medical University

� A 45 years old female with rectal bleeding � What is your differential diagnosis?

Rectal Bleeding �Hemorrhoid �Colorectyal cancer �Diverticulitis �Anal fissure �Rectal polyp �Solitary ulcer �Poroctits �Rectal prolapse �Rectal trauma �Preanal abscess �Preanal fistula �Angiodysplasia �colitis

Hemorrhoid Definition Often described as "varicose veins of the anus and rectum", hemorrhoids are enlarged, bulging blood vessels in and about the anus and lower rectum. There are two types of hemorrhoid

Hemorrhoid History �Hemorrhoids pre-date Hippocrates, the ancient Greek physician considered to be among the most important figures in the history of medicine. �Hemorrhoids were mentioned by the Egyptians, Indians and all cultures in the ancient world. The oldest anatomical books that mention hemorrhoids are in the Egyptian Ebers papyrus. Estimated to have been written around 3000 BC, it mentions hemorrhoids, rectal prolapse, intestinal parasites etc. �Hippocrates treated hemorrhoids by cauterization, excision and ligation. So things haven’t changed that much! We are still treating hemorrhoids by burning, ligation and surgical removal.

Epidemiology They are extremely common and estimated to be present in up to 50 percent of the population by age 50.

Symptoms �External hemorrhoids �Internal hemorrhoids �Rectal pain occurs mainly �The most common symptom with external hemorrhoids. of internal hemorrhoids is Blood may pool under the rectal bleeding. You may skin, forming a hard, painful find bright red streaks of lump. This is called a blood on the toilet paper or thrombosed, or clotted, bright red blood in the toilet hemorrhoid. You might also bowl after having a normal notice streaks of blood on the bowel movement. Blood also toilet paper after straining to may be visible on the surface pass a stool. of the stool.

What causes hemorrhoids? �Normally, tissue inside the anus fills with blood to help control bowel movements. If you strain to move stool, the increased pressure causes the veins in this tissue to swell and stretch. This can cause hemorrhoids. �Diarrhea or constipation also may lead to straining and can increase pressure on veins in the anal canal. �Pregnant women can get hemorrhoids during the last 6 months of pregnancy. This is because of increased pressure on the blood vessels in the pelvic area. Straining to push the baby out during labor can make hemorrhoids worse. �Being overweight can also lead to hemorrhoids

What causes hemorrhoids? �Liver disease, heart disease, or both. These conditions may cause blood to back up in the pelvis and abdomen. �Prolonged sitting or standing. This may cause blood to pool in the anal area and increase pressure on the veins. �Frequent heavy lifting or holding your breath when lifting heavy objects. This can cause a sudden increase of pressure in blood vessels

The diagnosis of hemorrhoids is based on �medical history �physical exam �digital rectal exam �Endoscopy �Flexible sigmoidoscopy �Barium enema �Colonoscopy

Treatment Overview �Most hemorrhoids can be treated with simple changes to diet and bowel habits �Fixative procedures include tying off the hemorrhoids with a rubber band (rubber band ligation) or using heat, lasers, or electric current to create scar tissue (coagulation therapy). �Hemorrhoidectomy �Stapler

Prevention �Avoid constipation �Include fruits, vegetables, beans, and whole grains in your diet each day. These foods are high in fiber. �Drink plenty of fluids, enough so that your urine is light yellow or clear like water. �Get some exercise every day. Try to do moderate activity at least 2½ hours a week. Or try to do vigorous activity at least 1¼ hours a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.

�Take a fiber supplement, such as Citrucel or Metamucil, every day if needed. Start with a small dose and very slowly increase the dose over a month or more. �Schedule time each day for a bowel movement. Having a daily routine may help. Take your time and do not strain when having a bowel movement

Prevention �Practice healthy bowel habits �Go to the bathroom as soon as you have the urge. �Avoid straining to pass stools. Relax and give yourself time to let things happen naturally. �Avoid holding your breath while passing stools. �Avoid reading while sitting on the toilet. Get off the toilet as soon as you have finished.

Prevention �Modify your daily activities �Avoid prolonged sitting or standing. Take frequent short walks. �If possible, avoid lifting heavy objects frequently. If you must lift heavy objects, always exhale as you lift the object. Don't hold your breath when you lift. �If you are pregnant, sleeping on your side will lower pressure on the blood vessels in your pelvis. This can help keep hemorrhoids from becoming bigger.

Anal Fissures A 18 year old girl with anal pain after defecation

What are anal fissures? An anal fissure is a cut or tear occurring in the anus (the opening through which stool passes out of the body) that extends upwards into the anal canal.

Epidemiology Fissures are a common condition of the anus and anal canal and are responsible for 6 -15% of the visits to a colon and rectal (colorectal) surgeon. They affect men and women equally and both the young and the old. Fissures usually cause pain during bowel movements that often is severe. Anal fissure is the most common cause of rectal bleeding in infancy

What Are Anal Fissures? When the lining of the anal canal develops a tear or a sore (also called an ulcer), it is called an anal fissure. The anal canal is the last part of the rectum before the anus. Fissures can occur in just about anyone, but are more common in middle aged or young adults. A fissure can be difficult to heal because it causes a spasm in the anal sphincter and aggravates itself, creating a vicious cycle of pain and irritation.

EPIDEMIOLOGY �It is estimated that there approximately 100, 000 cases per year in the United States �The mean age for presentation of anal abscess and fistula disease is 40 years (range 20 to 60 �Adult males are twice as likely to develop an abscess and/or fistula compared with women � �The incidence of anal fissures is around 1 in 350 adults. They occur equally commonly in men and women and most often occur in young adults aged 15 to 40.

Causes �Anal sex �Constipation �Crohn's disease �Chronic use of laxatives �Immunodeficiency disorders �Leukemia �Multiple pregnancies

What are the symptoms of anal fissures �pain that worsens with bowel movements. �Bleeding �itching (pruritus ani), �malodorous discharge �Burn �Eczema �Fistula

How are anal fissures diagnosed and evaluated? �A careful history �gentle inspection �tag of skin at the edge of the anus (sentinel pile), �anal papilla at the upper end of the fissure �Sigmoidoscopy

What causes anal fissures? �Trauma �Hard stool �Diarrhea �Insertion of a rectal thermometer �Enema �Endoscope �Ultrasound probe

How are anal fissures treated? �The goal of treatment for anal fissures is to break the cycle of spasm of the anal sphincter and its repeated tearing of the anoderm �fiber diet. Additionally, patients are advised to avoid "sharp" foods that may not be well-digested �Sitz baths �Anesthetics and steroids

�surgery. �nitroglycerin. �botulism toxin �Diltiazem �Anal dilatation

Prognosis The prognosis is good for acute fissures; they generally heal with non-invasive treatments. The cure rate using LIS surgery for chronic fissures is also encouraging. LIS can be repeated if the fissure does not heal with the first surgery. Fissures do not cause cancer and complications are uncommon.

Anorectal Abscess A 28 year man with chills and fever He has pre anal pain too

Anorectal abscess There are four types of anorectal abscesses: perianal, ischiorectal, intersphincteric, and supralevator.

Incidence More common in males than in females. This differences this is due to (a) Anal cleanliness (b) Rougher type of undergarments causing greater friction on the perineal skin (c) Increase sweating in the anal region.

Classification �Perianal �Ischeorectal �Submucous �Pelvirectal

Clinical Features �acute pain �sneezing and defaecation. �swelling near the anus which is extremely tender on touching. �discharge of pus �moderate fever �fluctuation can be elicited �indurated bulge

Aetiology 1) Abrasion or tearing of the lining of the anal canal or of the perianal skin 2) Infection from an anal crypt via an anal gland. This theory has recently accured greater acceptance 3) Blood Borne Infection 4) Additional aetiological factors 5) Crohn's disease, Ulcerative colitis and tuberculosis

Aetiology �Dorsal anal fissure. �Anal hematoma. �Prolapsed thrombosed internal hemorrhoids. �Following injection of a anaesthetic solution or alcohol in perianal or ischiorectal space in the treatment of perianal pain. �Following injection of internal hemorrhoids is less frequent complication but may lead to abscess formation. �Injury to anal or rectal mucosa by nozzle of enema syringe. As a complication of hemorrhoidectomy operation

Signs and Symptoms �Pain �Constipation �drainage from the rectum �fever and chills �palpable mass near the anus �Fatigue �Night Sweat �Painful bowel movements

Diagnostic approach �medical history �physical exam �pelvic CT scan �MRI �trans-rectal ultrasound

Treatment

Fistula A 32 year old man with history of pre anal abscess and pre anal discharge

Fistula �Is an abnormal connection or pathway between two epithelium-lined organs that normally do not connect

Symptoms �excrete pus �sometimes serous fluid and rarely feces �pruritus ani �Itching �skin maceration. �recurrent abscess formation

Diagnosis �History �PE �instillation of methylene blue solution �Fistulography �MRI �Endosonography

Therapy �Surgery (fistulotomy – fistulectomy – seton insertion - curettage and …. ) �Mucosal advancement flap- Marsupialization �Non surgery (glue – plug -laser……. . )

Pilonidal Disease �What is your diagnosis about an 18 years old man who complains of inter gluteal pain?

�Pilonidal disease was first reported in 1833. This process was first described by Anderson in 1847 and later named pilonidal sinus by Hodges. . .

Pilonidal Disease Pilonidal disease (cyst, infection) consists of a haircontaining sinus or abscess occurring in the intergluteal cleft. Although the etiology is unknown, it is speculated that the cleft creates a suction that draws hair into the midline pits when a patients sits. These ingrown hairs may then become infected and present acutely as an abscess in the sacrococcygeal region. Once an acute episode has resolved, recurrence is common.

�Pilonidal disease is a chronic skin infection in the crease of the buttocks near the coccyx (tailbone). It is more common in men than women and most often occurs between puberty and age 40. Obesity and thick, stiff body hair make people more prone to pilonidal disease.

Treatment �An acute abscess should be incised and drained as soon as the diagnosis is made. �In chronic patient total excision is choice